Referral Form

Use this service to submit your interest in receiving short-term counselling or mentoring from YPI Counselling. This service is primarily available to young people within the Basingstoke and Deane area.

YPI Counselling is not a Crisis service and a waiting list system is in place. We see all clients in order by the date of when a referral is received.

We offer short-term counselling which may not be safe or effective if you have a severe mental health condition such as PTSD, an eating disorder, or personality disorder. We recommend talking to your GP about a referral to CAMHS or mental health services.

If you need urgent help or support in a crisis

If you need more immediate support please consider the following:

Request an urgent appointment with your GP
Attend your local A&E department
Call NHS 111 or 999
Text SHOUT to 85258
(Under 18's) Contact Child Line on 0800 111
(Over 18's) Contact the Samaritans on 116 123
Online chat: www.kooth.com
Self-help: www.youngminds.org

Please note we cannot work with people under an Adoption or Special Guardianship Order. Please contact Barnardo's for further information and support or see link below:

www.barnardos.org.uk/what-we-do

Before you start

You can also register by printing off our referral form.

You cannot register for this service if you live outside of the UK.

Submission takes around 10 minutes.

Start

Self Referral Form

Is this referral

For yourself?

For a child or young person in your care?

Information about the person having counselling or mentoring

First Name:

Surname:

Street Address:

Town:

Postcode:

GP Surgery:

Gender:

Ethnicity:

Date of Birth

Day:

Month:

Year:

Which sexual orientation do you identify as?

Contact information

Please provide a phone number and email address that you consent to YPI using to make and confirm appointments with you.

Name:

Phone Number:

Email Address:

Emergency contact information

Please provide a phone number for use in an emergency.

Name:

Phone Number:

Work/Education Status

School/College:

Work Status:

Living Situation:

Do you have a disability or a mental health condition?

Please only provide this information if you have been diagnosed by a Health Professional such as a doctor, consultant, or psychiatrist.

Yes

Please provide details:

Date Diagnosed:
Day:	Month:	Year:
Name of doctor or consultant:

Name of medical centre/hospital:

Diagnosis:

What are the main reasons you would like to have counselling support?

Please tell us about the problems you are having with your mental health, feelings, relationships or other issues in your life.

Do you have any thoughts or behaviours which could cause harm to you or others?

For example, let us know if you are self-harming, making plans to take your life, regularly taking drugs or drinking a lot, or feeling violent towards others.

Are you currently receiving any mental health treatment or support?

Yes

Please provide details:

1	Type of Support:

	Name of therapist, doctor, or consultant:

	Details of any medication you are taking:

Are you a parent and under 18?

Yes

Are you a young carer?

Yes

Do you suffer from poverty issues?

Yes

Are you currently in care, or under the Child Protection Plan or Child In Need Plan?

Yes

Are you involved with the Courts?

For example, are you part of an ongoing police investigation, being called as a witness or have you committed a criminal act.

Yes

If you are a parent, guardian, or professional completing this form on behalf of a child or young person, please complete your own details:

Name of Referring Organisation: If you are this individual's parent or guardian, please leave this blank.

Name:

Relationship to young person:

Referrer Telephone:

Referrer Email Address:

How did you hear about YPI?

Would like to receive YPI’s Quarterly Newsletter with updates on our services, fundraising, and signposting information?

Yes

Contact Us

Call us on:
01256 423 878
Email us at:
office@ypicounselling.co.uk
We are open:
Mon to Fri - 10 AM to 3 PM

Portal

Referral Form

If you need urgent help or support in a crisis

Before you start

Self Referral Form

Is this referral

Information about the person having counselling or mentoring

Date of Birth

Which sexual orientation do you identify as?

Contact information

Emergency contact information

Work/Education Status

Do you have a disability or a mental health condition?

What are the main reasons you would like to have counselling support?

Do you have any thoughts or behaviours which could cause harm to you or others?

Are you currently receiving any mental health treatment or support?

Are you a parent and under 18?

Are you a young carer?

Do you suffer from poverty issues?

Are you currently in care, or under the Child Protection Plan or Child In Need Plan?

Are you involved with the Courts?

If you are a parent, guardian, or professional completing this form on behalf of a child or young person, please complete your own details:

How did you hear about YPI?

Would like to receive YPI’s Quarterly Newsletter with updates on our services, fundraising, and signposting information?

Please acknowledge the following statement:

Please acknowledge the following statement:

Contact Us